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PekkaRaatikainen

Symptoms of Arrhythmia and Examination of an Arrhythmia Patient

Essentials

  • Patient's medical history, clinical examination and resting ECG are the cornerstones for diagnosis and treatment of arrhythmias.
    • The majority of severe heart diseases can be excluded with a careful medical history and a thorough clinical examination.
    • For the identification of rare inherited severe arrhythmias it is essential to record the patient's family history.
    • Resting ECG often provides valuable diagnostic clues concerning the aetiology of the symptom.
  • If the patient has a basically healthy heart, his/her functional capacity is normal, the arrhythmia does not cause haemodynamic problems (syncope) and there is no family history of sudden deaths or severe arrhythmias, the arrhythmia is almost without exception benign.
  • Consider an arrhythmia always dangerous if it causes a serious haemodynamic disturbance (syncope or presyncope) or if it is associated with a severe heart disease. The investigation of such arrhythmias demands cardiological expertise and often extensive examinations.
  • It is necessary to make a distinction between arrhythmias of atrial and ventricular origin because this affects both the prognosis and the choice of treatment options. Consider wide-complex tachycardia always to be ventricular until proven otherwise.
  • Except for atrial fibrillation, the treatment of a symptomless arrhythmia is only seldom necessary (even a symptomless atrial fibrillation increases the risk of thromboembolism and is an indication for anticoagulation therapy).

Symptoms caused by arrhythmiasScreening for Atrial Fibrillation

Sensations of palpitation

  • Palpitation is the most common symptom caused by an arrhythmia.
  • The range of palpitation sensations is wide and the symptoms may vary from a single ”somersault” to unbearable throbbing of the heart. Somersaults are usually caused by extrasystoles.
  • Careful assessment of the nature of the patient's sensations (see below Patient history and clinical examination) may often lead to a quite specific diagnosis of an arrhythmia.

Disturbance of consciousness

  • Disturbance of consciousness (syncope Syncope: Causes and Investigations) caused by an arrhythmia is always a sign of a serious problem. It must be differentiated from vasovagal collapse and other benign causes of disturbed consciousness.
    • In both cases the world goes black in the patient's eyes, muscle strength is lost and the patient slumps down, but the ”normal fainting” caused by a vasovagal reaction is often associated with stressful situations (e.g., taking a blood sample).
    • The patient history also quite reliably helps in the identification of collapses that are associated with vasovagal stimuli (vomiting, coughing, voiding).
    • The differentiation of a so called ”nitroglycerin collapse” from a syncope caused by an arrhythmia is easy with a careful patient history.
    • After an epileptic attack the patient is often drowsy and tired whereas a patient recovering from a cardiac collapse is lively. The differential diagnosis is complicated by the fact that even a prolonged cardiac syncope may often be accompanied by seizures.

Other symptoms

  • Arrhythmias may cause weakness, dyspnoea, chest pain, and many other non-specific symptoms that often are associated with the patient's primary diseases.

Grading of symptoms

  • The EHRA score is recommended for assessing the severity of symptoms in atrial fibrillation.
    • EHRA 1: No symptoms
    • EHRA 2: Mild symptoms; normal daily activity not affected
    • EHRA 3: Severe symptoms; normal daily activity affected
    • EHRA 4: Disabling symptoms; normal daily activity discontinued
  • Other arrhythmias can be graded e.g. by the effects they have on haemodynamics or on the quality of life of the patient.

Patient history

History and characteristics of the attacks

  • When did the arrhythmias start?
    • Palpitation spells that have occurred since childhood suggest a supraventricular arrhythmia (SVT).
    • Arrhythmias that started after a myocardial infarction are probably ventricular.
  • The frequency and duration of the attacks
  • Mode of onset and termination
    • Supraventricular tachycardia starts and stops suddenly like snapping your fingers.
    • Sinus tachycardia starts and stops gradually.
    • Vagus stimulation stops supraventricular tachycardia but has little effect on sinus tachycardia, atrial fibrillation or ventricular tachycardia.
  • Pulse rate and character during the arrhythmia
    • Extrasystoles: single ”sommersaults” or ”skipping” of a beat
    • Supraventricular tachycardia: even, rapid pulsation (picture 1)
    • Atrial fibrillation: the rhythm is completely ”in a muddle” (picture 2)
    • Teach the patient to feel his or her pulse (for example, from the carotid artery) and to count the pulse rate during the arrhythmia. In the screening of atrial fibrillation, also mobile phone applications and other portable devices can be used.
  • The effect of the arrhythmia on the patient's haemodynamics (syncope)
  • The effect of the symptoms on the patient's working capacity and quality of life
    • EHRA score in atrial fibrillation
  • Provoking factors: coffee, deprivation of sleep, strain, stress, etc.

Primary diseases

  • Arrhythmias causing sensations of palpitation in persons with a healthy heart usually have benign prognosis and rarely require treatment.
  • In cardiac diseases (e.g. in patients who have had myocardial infarction) they may be predictive of life-threatening arrhythmias. Such patients should always be referred for further cardiological investigations and treatment.
  • Other underlying conditions that have a great impact on the investigations and treatment of a patient with arrhythmia include, among others, disorders of the thyroid, liver and kidneys.

Pharmacological and other treatments

  • Check whether the medication for the cardiac and other underlying conditions predisposing to arrhythmias is in accordance with clinical guidelines and refer the patient, if indicated, to invasive investigations and treatment.
  • Check whether the pharmacotherapy (or other treatment) for the underlying condition may explain the arrhythmia.
    • Beta blockers, calcium channel blockers and digoxin often cause bradycardia.
    • Sympathomimetic drugs and some psychoactive drugs may cause (sinus)tachycardia.
    • Drugs that prolong the QT interval predispose to torsades de pointes ventricular tachycardia.
    • Harmful pharmacological interactions
    • Tachycardia and flutter of the left atrium occasionally occurs after ablation therapy for atrial fibrillation.
  • Find out about the efficacy and adverse effects of the current and earlier antiarrhythmic medication.

Family history

  • Serious ventricular arrhythmia or sudden unexplained death in first-degree relatives raises the suspicion of a hereditary arrhythmia disorder.
  • Close relatives of patients with atrial fibrillation have a 2-3 fold risk of acquiring atrial fibrillation. Predisposition to supraventricular tachycardia may also be familial.

Clinical examination

Basic examination

  • Clinical examination
    • Auscultation of the heart and the carotid arteries (murmurs)
    • Auscultation of the lungs (e.g. rales suggesting heart failure)
    • Blood pressure
    • 12-lead electrocardiography
      • Heart rate, atrio-ventricular conduction (PQ-interval), intraventricular conduction defects (bundle branch or fascicular block), hypertrophies, pathological Q-waves, disturbances in repolarisation (QT-interval), delta-wave
  • Laboratory investigations
    • Basic blood count, plasma sodium, potassium, creatinine, fasting blood glucose, lipids
    • Thyroid-stimulating hormone (TSH) at least in patients with atrial fibrillation and with rapid arrhythmias
    • Other investigations on the basis of the patient's clinical condition
  • Chest x-ray if the patient history or the clinical examination suggest a cardiac or pulmonary disease.

Further investigations

  • The need for further examinations must always be considered individually, as in most cases the basic examinations are sufficient.
  • EchocardiographyEchocardiography as an Outpatient Procedure if the patient (or a close relative) has been diagnosed with
    • a myocardial infarction
    • cardiomyopathy
    • decreased functional capacity
    • a suspicious murmur
    • signs of left ventricular hypertrophy in the ECG
    • an exceptionally large cardiac shadow in the chest x-ray.
  • Clinical exercise testExercise Stress Test if
    • there are sensations of arrhythmia during exertion
    • the patient's functional capacity is decreased
    • the patient's symptoms suggest coronary heart disease.
  • 24-hour ambulatory ECG recording (Holter Ambulatory ECG Monitoring) if the patient frequently has sensations of arrhythmia or otherwise disabling attacks
  • Event-ECG (the patient starts the ECG recording during symptoms) is often better than ordinary Holter recording in the investigation of palpitation sensations that occur rarely.
  • Implantable ECG monitor is a good method for investigating infrequently occurring acute disturbances of consciousness (syncope).
  • According to a cardiologist's consideration: cardiac and coronary angiography, electrophysiological examination, cardiac CT or MRI imaging, or genetic examinations

References

  • Raviele A, Giada F, Bergfeldt L et al. Management of patients with palpitations: a position paper from the European Heart Rhythm Association. Europace 2011;13(7):920-34. [PubMed]

Evidence Summaries ⬆